Clinical Documentation Specialist

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.Job Type:RegularScheduled Hours:40Work Shift:Day (United States of America)40hpw; Day Shift; Monday- FridayJob Description:Duties/Responsibilities:

Concurrently reviews inpatient records to ensure completeness, accuracy and clinical validation.

Evaluates documentation for assignment of working and possible DRG.

Recognizes opportunities for documentation improvement including severity of illness, risk of mortality, core measures, and patient safety/quality.

Queries physicians regarding missing, unclear or conflicting documentation. Requests and obtains additional documentation when needed. Follows up on all unanswered queries.

Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.

Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.

Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing and case management.

Performs mortality reviews and optimizes risk of mortality.

Maintains review worksheet on all records using CDI software.

Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.

Reviews, evaluates, analyzes and interprets data related to documentation on an ongoing basis. Identifies trends or potential problems and assists in developing action plans to address.

Adheres to ethical and professional business practices.

All other duties as assigned.

It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Education/Experience Required:

BSN

At least 5 years of medical/surgical nursing experience in the acute hospital setting.

Critical Care and/or Emergency Nursing experience required.

Organizational and critical thinking skills required.

Registration/Certification:

MA RN licensure required.

Physical/Environmental RequirementsThis job requires frequent bending, carrying, pulling, pushing, reaching, standing, stooping, walking and lifting over 10 lbs. There will be occasional need for climbing stairs, lifting in excess of 50 – 100 lbs and sitting. Constant use of hearing, sight and speech. Frequent use of smell and touch. Frequent keyboard and telephone use. Constant concentration and problem solving.FLSA Status:ExemptAs a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.Equal Opportunity Employer/Veterans/Disabled